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NCCPCThe National Collaborating Centre for Primary Care

Postnatal careRoutine postnatal care of women and their babiesJuly 2006

Cite as: Demott K, Bick D, Norman R, Ritchie G, Turnbull N, Adams C, Barry C, Byrom S, Elliman D, Marchant S, Mccandlish R, Mellows H, Neale C, Parkar M, Tait P, Taylor C, (2006) Clinical Guidelines And Evidence Review For Post Natal Care: Routine Post Natal Care Of Recently Delivered Women And Their Babies London: National Collaborating Centre For Primary Care And Royal College Of General Practitioners.

TABLE OF CONTENTS PREFACE 1 22.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11

5 6 89 10 12 13 15 17 24 35 38 39 41

KEY PRIORITIES FOR IMPLEMENTATION INTRODUCTIONBackground Need for the guideline Woman and baby centred care Aim of the guideline Scope Responsibility and support for guideline development Care Pathway Research Recommendations Acknowledgements Glossary Urgency action levels

33.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11

METHODSIntroduction Developing Key Clinical Questions Literature search strategy Identifying the Evidence Critical appraisal of the evidence Economic analysis Assigning levels to the evidence Forming recommendations Areas without evidence and consensus methodology Consultation The Relationship between the guideline and other national guidance

4242 42 43 44 45 45 46 48 48 49 50

44.1 4.2 4.3 4.4 4.5 4.6 4.7

PLANNING THE CONTENT AND DELIVERY OF CARERecommendations Evidence Statements for Planning Care Principles of care Professional Communication What are the necessary competencies for postnatal care? Is there an optimal length of stay on the postnatal ward? What are the models for delivering the care?

5353 55 58 59 63 63 71

4.8 What is the optimal number of postnatal contacts for the best outcomes? What needs to be done at what time? 89

55.1

MAINTAINING MATERNAL HEALTHRecommendations

9191

5.2 5.3 5.4 5.5 5.6

Evidence Statements for Maternal Health Introduction Major Physical Morbidities Mental Health and Well being Physical Health and Well being

102 111 113 136 152

66.1 6.2 6.3 6.4

INFANT FEEDINGRecommendations Evidence Statements for Infant Feeding Breastfeeding Feeding formula milk

190190 200 207 253

77.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8

MAINTAINING INFANT HEALTHRecommendations Evidence Statements for Infant Health The healthy baby Emotional Attachment and Parenting Physical Examinations and Screening Physical Health and Well being Vitamin K Safety

257257 269 274 274 282 290 308 316

8

REFERENCES

342

APPENDICES (Separate document) Appendix A Audit Criteria Appendix B Scope Appendix C - Clinical Evidence Extractions Appendix D Health Economic Extractions Appendix E - Clinical Questions

PrefaceThe postnatal period marks the establishment of a new phase of family life for women and their partners and the beginning of the lifelong health record for newborn babies. As a practicing GP I know just how important this period is and the vital role of the primary health care team. But I also know that it is essential to define clear standards of health care for this area as there is uncertainty about best practice. So I welcome this document which places the woman and her infant at the centre of care. Patient centred care is a value espoused by the Royal College of General Practitioners. In our document, Valuing General Practice, we outlined the core values of British general practice.1 The guiding principles of practice identified by the College includes the concepts that health care must be a partnership with patients and involve a team approach in which professionals work in an integrated, co-ordinated manner. The Postnatal Care Guideline, developed by the National Collaborating Centre for Primary Care, based at the RCGP, reflects these precepts of contemporary general practice. Core care for all women is defined with consideration for the context of care as well as the specific needs and preferences of the individual woman. In addition to providing clinical guidance about particular topics, the recommendations cover the importance of offering appropriate, responsive and timely information and of promoting health. Team working is a key feature of current general practice. The Postnatal Care Guideline recognizes the necessary flexibility of healthcare professionals roles in evolving health care systems and highlights the need for coordination of care throughout the postnatal period. Effective communication between health care professionals is therefore identified as a necessary element in the delivery of high quality and cost effective care. I commend this guidance to health communities including commissioners and urge them to implement it. The guidelines will ensure that the primary care focus during the puerperium is maintained and that it meets the needs of women, their families and the community, and ensures the appropriate use of health care resources.

Professor Mayur Lakhani , Chairman of Council, Royal College of General Practitioners, London SW7 1PU1

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Key priorities for implementation

The following recommendations have been identified as priorities for implementation. A documented, individualised postnatal care plan should be developed with the woman, ideally in the antenatal period or as soon as possible after birth to include: relevant factors from the antenatal, intrapartum and immediate postnatal period details of the healthcare professionals involved in her care and that of her baby including roles and contact details plans for the postnatal period.

This should be reviewed at each postnatal contact. There should be local protocols about written communication, in particular about the transfer of care between clinical sectors and healthcare professionals. These protocols should be audited. Women should be offered relevant and timely information to enable them to promote their own and their babies health and well-being and to recognise and respond to problems. At the first postnatal contact, women should be advised of the signs and symptoms of potentially life-threatening conditions (given in Table 5-1) and to contact their healthcare professional immediately or call for emergency help if any signs and symptoms occur. All maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated structured programme that encourages breastfeeding, using the Baby Friendly Initiative (www.babyfriendly.org.uk) as a minimum standard. 6 of 393Postnatal care: Routine postnatal pare of women and their babies (July 2006)

At each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the womans normal pattern.

At each postnatal contact parents should be offered information and advice to enable them to: assess their babys general condition identify signs and symptoms of common health problems seen in babies contact a healthcare professional or emergency service if required.

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Introduction

Postnatal care is pre-eminently about the provision of a supportive environment in which a woman, her baby and the wider family can begin their new life together. It is not the management of a condition or an acute situation. This guideline has been written within a conceptual framework which places the woman and her baby at the centre of care, appreciating that all postnatal care should be delivered in partnership with the woman and should be individualised to meet the needs of each mother-infant dyad. The guideline aims to identify the essential core care which every woman and her baby should receive, as appropriate to their needs, during the first 6-8 weeks after birth, based upon the best evidence available. A key component of the guideline is information to empower the woman to care for her baby and herself so as to promote their longer-term physiological and emotional well-being. The guidance on the information which the healthcare professional should offer women and their partners/families is listed, for convenience, in Tables 5-1, 6-1 and 7-2. These cover information about maternal health, infant feeding and infant health, respectively. The guideline also cross refers to the Department of Health publication Birth to Five (Department of Health. 2005) which has a wealth of information for the woman on the postnatal period and baby care which has not been duplicated in this guideline. Although for most women and babies, the postnatal period is uncomplicated, core postnatal care is also about recognising any deviation from expected recovery after birth and then about evaluating and intervening appropriately. The guideline gives advice on when additional care may be required. These recommendations have been given an appropriate status level indicating the degree of urgency in dealing with the problem. The status levels are defined in Table 2-1. If additional care is required it should be offered so as to minimise, as much as possible, any impact on the relationship between the woman and her baby. 8 of 393Postnatal care: Routine postnatal pare of women and their babies (July 2006)

2.1

Background

Current models of postnatal care originate from the beginning of the 20th century, when